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Navigating the Gender Spectrum: A General Overview of Transgender Health Care

Navigating the Gender Spectrum: A General Overview of Transgender Health Care

Teaser: 

Dr. Adam C. Millar, MD, MScCH, FRCPC,

Mount Sinai Hospital, Assistant Professor, Division of Endocrinology and Metabolism, Department of Medicine, University of Toronto, Toronto, ON.

CLINICAL TOOLS

Abstract:Transgenderism is common, with quoted prevalence rates of between 0.5-1% of the population.1,2,3 The term "transgender" reflects a broad spectrum of identities, including agender, pangender, genderqueer and genderfluid. Although there is increased public recognition of transgender issues, many physicians remain uncomfortable managing matters of transgender health. There is a paucity of high quality, long term randomized controlled trials on many transgender health topics, requiring physicians to rely largely on consensus guidelines. Integration of transgender-related subject matter into medical school curricula is one of the first steps towards enabling future physicians to increase their comfort in transgender health care.
Key Words: Transgender, trans, testosterone, estrogen, androgen blockade.

Members of the College of Family Physicians of Canada may claim MAINPRO-M2 Credits for this unaccredited educational program.

www.cfpc.ca/Mainpro_M2

You can take quizzes without subscribing; however, your results will not be stored. Subscribers will have access to their quiz results for future reference.

1. Transgenderism is not limited to the binary gender constructs of male and female. The term "transgender" includes a broad spectrum of identities, including agender, pangender, genderfluid and genderqueer.
2. Lack of physician comfort with medical management of the transgender patient has been linked to increased rates of refusal of medical care, as well as verbal harassment and in extreme cases physical assault.
3. Due in part to a lack of large randomized controlled trials, many transgender guideline recommendations are based on expert opinion and relatively low quality evidence.
Rather than assume one's gender identity, it is advisable to ask the patient how they identify, and what pronouns are preferred.
There are no specific hormonal targets during transition therapy. Instead, treatment targets are defined by the patient's goals and overall sense of well-being.
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La testostérone et la prostate

La testostérone et la prostate

Teaser: 

L’amélioration de la vie chez les hommes vieillissants : envisager l’importance de la testostérone

La testostérone et la prostate

Conférencier: Gerald Brock, M.D., FRCPC, Professeur, Département de la chirurgie, Division de l’urologie, Université de Western Ontario, London, ON.

L’aspect sécurité en ce qui concerne la prostate, est d’une importance clinique chez les hommes qui reçoivent une thérapie de remplacement de l’androgène. Le Dr Gerald Brock a exprimé l’espoir que sa discussion « La testostérone et la prostate » contribue à une meilleure compréhension, aille à l’encontre de la désinformation courante et appuie le consensus croissant qu’un faible taux de testostérone a des effets néfastes sur la santé. Il a souligné qu’un faible taux de testostérone ne confère aucune protection contre le cancer de la prostate, et le traitement des hommes atteints d’hypogonadisme n’augmente pas les risques de cancer de la prostate.
Quels sont les risques et les bienfaits du traitement chez les patients atteints d’hypogonadisme? Le Dr Brock a présenté une étude de cas illustrative et a questionné l’auditoire concernant leurs attitudes envers un traitement à testostérone exogène.

Le Dr Brock a demandé aux auditeurs s’ils considéreraient un patient âgé de 56 ans, avec une perte de la libido, une baisse d’énergie et un léger dysfonctionnement érectile, comme étant un bon candidat pour recevoir des suppléments de testostérone. Le patient a préalablement été vu pour l’hypertension artérielle et un taux de cholestérol élevé, il prend des médicaments pour l’hypertension artérielle et a de légers symptômes de l’hypertrophie bénigne de la prostate. De plus, le cancer de la prostate figure dans ses antécédents familiaux et son dernier taux sérique d’antigène prostatique spécifique (APS) était de 2.2ng/dl; son toucher rectal était normal. Un test a démontré un taux de testostérone total de 5 (N=6 à 26).

Dans ce cas, malgré que le patient démontre un profil adéquat de symptômes, la réaction de l’auditoire suggère une réticence générale à traiter avec un supplément de testostérone. De plus, a-t-il rappelé aux auditeurs, la testostérone améliore plusieurs des manifestations physiques inquiétantes desquelles ont discuté le Dr Jeremy Gilbert et le Dr Juan Carlos Monge.

Le Dr Brock a conclu d’après l’hésitation que le présumé profil risque-bienfait d’un supplément de testostérone limite les pratiques cliniques. Il avait espéré que l’information présentée les aurait encouragés d’utiliser leur jugement clinique pour décider qui devrait être traité et qui devrait être exclu du traitement.

Il a résumé des données de l’Étude longitudinale sur le vieillissement menée à Baltimore, qui ont démontré que les taux d’hypogonadisme croissent avec l’âge et que le pourcentage des hommes atteints d’hypogonadisme augmente progressivement après l’âge de 50 ans.1

Des études démontrent qu’un faible niveau du total de la testostérone prédit le développement d’une aggravation des facteurs de risque pour le syndrome métabolique et le diabète. Ces résultats indiquent que l’hypoandrogénie est un indicateur précoce des perturbations de l’insuline et du métabolisme du glucose, et peut progresser au syndrome métabolique ou au diabète.2 De plus, une étude de Shores et coll. a établi que l’espérance de vie était plus courte chez les hommes avec des niveaux de testostérone faibles ou équivoques que chez ceux avec des niveaux de testostérone normaux.3 La mortalité toutes causes était de 34.9 % chez les hommes avec des niveaux faibles de testostérone, 24.6 % chez les hommes avec des niveaux équivoques de testostérone et 20.1 % chez les hommes avec des niveaux normaux de testostérone.

Malgré la présentation de preuves positives qui démontrent une relation inverse et favorable entre la concentration plasmatique de testostérone et les événements cardiovasculaires ainsi que les facteurs de risques métaboliques, il comprend que compromettre le risque de cancer est une grande source d’inquiétude pour ceux qui font de la pratique clinique. Le Dr Brock a assuré que les suppléments de testostérone n’ont pas impacté de façon négative les hommes atteints d’hypogonadisme dont les résultats d’examens et de tests de laboratoires étaient non soucieux. Les preuves suggèrent que les patients atteints d’hypo-gonadisme connaitront des bienfaits concrets en ce qui concerne un état de santé général.

Le Dr Brock a déclaré qu’il existe peu de preuves, que selon l’opinion générale, des taux de testostérone plus élevés représentent un facteur de risque pour le cancer de la prostate. Les données démontrent que le cancer se présente au moins aussi fréquemment chez les hommes avec un faible taux de testostérone que chez les hommes avec un taux plus élevé. Effectivement, de récentes preuves suggèrent que les hommes avec un faible taux de testostérone risquent de développer un cancer agressif de la prostate. Les chercheurs d’une étude récente ont conclu que le risque de développer le cancer de la prostate était doublé chez les hommes avec les taux de testostérone les plus faibles.4 De plus, la forme sous laquelle la testostérone est administrée ne change pas le niveau de risque : des études chez les hommes atteints d’hypogonadisme recevant une thérapie de testostérone de façon transdermique, topique, par injection intramusculaire ou par une combinaison de ces méthodes, ont démontré une faible fréquence du cancer de la prostate.5

Le Dr Brock a résumé des données d’études démontrant qu’un patient qui suit un régime de testostérone à long terme peut subir une légère augmentation du taux de l’APS (malgré que plusieurs études ne démontrent pas cette augmentation), qui demeure en dedans des normes.6 Les tests vont démontrer une légère augmentation de l’hémoglobine et des valeurs de l’hématocrite, mais du côté positif, il y a une amélioration de la note sur l’Échelle des symptômes des hommes vieillissants. Somme toute, les recherches sur l’impact de la testostérone sur les tissus de la prostate n’ont démontré aucun changement dans les concentrations d’androgène prostatique. Dans la plupart des cas, toute augmentation de l’APS demeure en dedans des normes.

Il a rappelé à l’auditoire que le guide de pratique clinique de l’Endocrine Society recommande un toucher rectal de la prostate et une mesure de l’APS avant d’entreprendre une thérapie de remplacement de la testostérone. Les antécédents familiaux sont très importants dans l’évaluation de la santé de la prostate. Le fait d’avoir un parent au premier degré atteint du cancer de la prostate double les risques du patient. Selon son point de vue et d’après le poids de la preuve, traiter les hommes atteints d’hypogonadisme avec de la testostérone n’est pas une inquiétude, pour autant qu’ils soient surveillés de près. Certaines données suggèrent que le risque réel se trouve chez les patients avec un faible taux de testostérone, qui seraient peut-être à risque d’être atteints d’un grade plus élevé du cancer de la prostate.7

Le Dr Brock a souligné qu’il ne préconise pas que les médecins traitent les patients atteints du cancer de la prostate avec de la testostérone, mais s’ils choisissent de le faire chez les hommes atteints d’hypogonadisme symptomatique et qu’une évaluation des risques est donnée, il ne devrait exister aucune inquiétude que les suppléments de testostérone soient périlleux. Autant que le patient soit symptomatique, que les examens et les résultats de tests de laboratoires soient non soucieux et qu’il soit suivi de près avec des tests et des touchers rectaux, le traitement n’est pas risqué. Des études ont montré que les hommes atteints d’hypogonadisme recevant une thérapie de remplacement de l’androgène ne démontrent aucune preuve d’un taux élevé de l’APS, la récidive du cancer ou la dispersion du cancer (Figure 1).8,9



 


En conclusion, le Dr Brock a souligné que des niveaux normaux de testostérone sont importants pour un bon état de santé et pour le bien-être sexuel. Les bienfaits cliniques de la thérapie de testostérone incluent une libido améliorée, une bonne fonction érectile, une meilleure santé cardiovasculaire, des risques réduits du syndrome métabolique et une meilleure composition corporelle. Il n’existe aucune preuve que la testostérone augmente le risque de cancer de la prostate, et certaines preuves suggèrent que l’hypogonadisme augmente le risque du cancer agressif de la prostate. Il est de plus en plus entendu que l’hypogonadisme et non son traitement correspond à de multiples résultats pauvres de la santé, et est un diagnostic véritablement inquiétant.

Références :

  1. Harman SM, Metter EJ, Tobin JD, Pearson J, Blackman MR; Baltimore Longitudinal Study of Aging. Longitudinal effects of aging on serum total and free testosterone levels in healthy men. J Clin Endocrinol Metab 2001;86:724–31.
  2. Laaksonen DE, Niskanen L, Punnonen K, et al. Testosterone and sex hormone-binding globulin predict the metabolic syndrome and diabetes in middle-aged men. Diabetes Care 2004;27:1036–41.
  3. Shores MM, Matsumoto AM, Sloan KL, et al.. Low serum testosterone and mortality in male veterans. Arch Intern Med. 2006;166:1660–5.
  4. Morgentaler A, Rhoden EL. Prevalence of prostate cancer among hypogonadal men with prostate-specific antigen levels of 4.0 ng/mL or less. Urology 2006;68:1263–7.
  5. Rhoden EL, Morgentaler A. Risks of testosterone-replacement therapy and recommendations for monitoring. N Engl J Med. 2004;350:482–92.
  6. Saad F, Gooren LJ, Haider A, Yassin A. A dose-response study of testosterone on sexual dysfunction and features of the metabolic syndrome using testosterone gel and parenteral testosterone undecanoate. J Androl. 2008;29:102–5.
  7. Schatzl G, Madersbacher S, Thurridl T, et al. High-grade prostate cancer is associated with low serum testosterone levels. Prostate. 2001;47:52–8.
  8. Agarwal PK, Oefelein MG. Testosterone replacement therapy after primary treatment for prostate cancer. J Urol. 2005;173:533–6.
  9. Kaufman JM, Graydon RJ. Androgen replacement after curative radical prostatec- tomy for prostate cancer in hypogonadal men. J Urol 2004;172:920–22.

Symposium parrainé par Solvay.

Testosterone and the Prostate

Testosterone and the Prostate

Teaser: 



 


Improving the Lives of Your Aging Male Patients: Considering Whether Testosterone Plays a Meaningful Role

Testosterone and the Prostate

Speaker: Gerald Brock, MD, FRCSC, Professor, Department of Surgery, Division of Urology, University of Western Ontario, London, ON.

In men receiving androgen replacement therapy, the safety aspects regarding the prostate are an area of clinical importance. Dr. Gerald Brock expressed the hope that his discussion “Testosterone and the Prostate” would contribute to greater understanding, counter prevalent misinformation, and support the growing consensus that having low testosterone has adverse health consequences. Low testosterone does not confer protective effects against prostate cancer, and treatment of hypogonadal men does not elevate prostate cancer risk, he stated.

What are the risks and benefits of treating hypogonadal patients? Dr. Brock offered an illustrative case study and queried the audience about their attitudes toward treatment with exogenous testosterone.

Dr. Brock questioned whether his example patient—a 56-year-old experiencing loss of sexual drive, low energy, and mild erectile dysfunction—would be considered by his listeners to be a good candidate for supplemental testosterone. The patient has been seen previously for hypertension and elevated cholesterol, is on hypertension medication, and has mild benign prostatic hypertrophy symptoms. Further, he has a family history of prostate cancer and his last prostate-specific antigen (PSA) was 2.2ng/dl; his digital rectal exam (DRE) is normal. On testing, his total testosterone returns at 5 (N=6–26).

The audience’s response suggested widespread reluctance to treat with supplemental testosterone in this patient’s case, despite having the appropriate symptom profile. Further, he reminded audience members, testosterone improves many of the physical endpoints of concern that Dr. Jeremy Gilbert and Dr. Juan Carlos Monge spoke of.

Dr. Brock inferred from the hesitancy that the presumed risk-benefit profile of supplemental testosterone constrains clinical practice. He hoped the information he provided would support their clinical judgement as to who to treat and who to exclude from treatment.
He reviewed data from the Baltimore Longitudinal Study of Aging that hypogonadism increases with age, and that the percentage of men with hypogonadism increases progressively after age 50 years.1

Studies show that low total testosterone levels predicts development of worsening risk factors for the metabolic syndrome and diabetes. These findings indicate that hypoandrogenism is an early marker for perturbations in insulin and glucose metabolism that may progress to metabolic syndrome or frank diabetes.2 Further, a study from Shores et al. found that survival times were shorter in men with low or equivocal testosterone levels than in those with normal testosterone levels.3 All-cause mortality was 34.9% in men with low testosterone levels, 24.6% in men with equivocal testosterone levels, and 20.1% in men with normal testosterone levels.

Despite the positive evidence presented as to the inverse and favourable relationship between plasma testosterone and cardiovascular events as well as metabolic risk factors, he understood that compromising cancer risk was a strong and mitigating concern for those in clinical practice. Dr. Brock assured that supplemental testosterone posed no impact on those hypogonadal men with nonconcerning exam and lab profiles. From an overall health perspective, study evidence suggests hypogonadal patients will likely experience concrete benefits.

The common view that higher testosterone represents a risk factor for prostate cancer has little evidentiary support, Dr. Brock stated. Data show that cancer occurs at least as commonly in men with low testosterone as in men with higher levels. Indeed, recent evidence suggests that those men with low testosterone are likely to have aggressive prostate cancer. A recent study’s investigators concluded that the risk of prostate cancer was doubled for men with the lowest testosterone values.4 Further, the form of testosterone given does not change the risk level: studies of hypogonadal men receiving testosterone therapy using transdermal, topical, intramuscular injection, or a combination of these preparations have demonstrated a low frequency of prostate cancer.5

Dr. Brock reviewed study data showing that if a patient is on a longer-term testosterone regimen, his PSA level may indeed increase slightly (although many studies do not show this), but only to the level of a eugonadal man.6 Test results will show a modest increase in hemoglobin, in hematocrit, but on the positive side, his scores on the Aging Male Symptom Scale improve. Ultimately, investigations of testosterone’s impact on prostate tissue have shown no change in prostatic androgen concentration. In most cases, any increase in PSA seen will stay in normal range.

He reminded the audience that the Endocrine Society’s clinical practice guideline recommends a DRE of the prostate and measurement of PSA before initiating testosterone therapy. In assessing prostate health, family history is very important. Having a first-degree relative with prostate cancer doubles a patient’s risk. From his perspective and the weight of the evidence, it is not a concern to treat hypogonadal men with testosterone as long as they are closely followed. Some data suggest that actual risk lies in that segment of patients with lower testosterone levels, who may be at risk for higher grade prostate cancer.7

Dr. Brock emphasized that he should not be understood as advocating that physicians treat their patients with prostate cancer with testosterone, but if they choose to do so, in cases where men are hypogonodal and symptomatic and a risk assessment is made, there are still no grounds for concern that supplemental testosterone is perilous. Provided the patient is symptomatic, has good exam and lab results, and is closely followed with testing and DREs, treatment is not unsafe. Studies have shown that hypogonadal men treated with androgen replacement therapy show no evidence of elevated PSA, cancer recurrence, or distant spread of cancer (Figure 1).8,9



 


In closing, Dr. Brock emphasized that eugonadal testosterone levels are important for good overall health and sexual well-being. Clinical benefits of testosterone therapy include improved libido, erectile function, better cardiovascular health, reduced metabolic syndrome risk factors, and better body composition. There is no evidence that testosterone increases prostate cancer risk, and some evidence suggests that hypogonadism increases aggressive prostate cancer risk. It is increasingly understood that hypogonadism and not its treatment is correlated with multiple poor health outcomes, and is a diagnosis of true concern.

References:

  1. Harman SM, Metter EJ, Tobin JD, Pearson J, Blackman MR; Baltimore Longitudinal Study of Aging. Longitudinal effects of aging on serum total and free testosterone levels in healthy men. J Clin Endocrinol Metab 2001;86:724–31.
  2. Laaksonen DE, Niskanen L, Punnonen K, et al. Testosterone and sex hormone-binding globulin predict the metabolic syndrome and diabetes in middle-aged men. Diabetes Care 2004;27:1036–41.
  3. Shores MM, Matsumoto AM, Sloan KL, et al.. Low serum testosterone and mortality in male veterans. Arch Intern Med 2006;166:1660–5.
  4. Morgentaler A, Rhoden EL. Prevalence of prostate cancer among hypogonadal men with prostate-specific antigen levels of 4.0 ng/mL or less. Urology 2006;68:1263–7.
  5. Rhoden EL, Morgentaler A. Risks of testosterone-replacement therapy and recommendations for monitoring. N Engl J Med 2004;350:482–92.
  6. Saad F, Gooren LJ, Haider A, Yassin A. A dose-response study of testosterone on sexual dysfunction and features of the metabolic syndrome using testosterone gel and parenteral testosterone undecanoate. J Androl 2008;29:102–5.
  7. Schatzl G, Madersbacher S, Thurridl T, et al. High-grade prostate cancer is associated with low serum testosterone levels. Prostate 2001;47:52–8.
  8. Agarwal PK, Oefelein MG. Testosterone replacement therapy after primary treatment for prostate cancer. J Urol 2005;173:533–6.
  9. Kaufman JM, Graydon RJ. Androgen replacement after curative radical prostatectomy for prostate cancer in hypogonadal men. J Urol 2004;172:920–22.

Sponsored by an unrestricted educational grant from Solvay Pharma Inc.

Aging and the Male Gonads

Aging and the Male Gonads

Teaser: 

 

Khaleeq ur Rehman, MBBS, MS(Urol), Department of Urology, McGill University, Montreal, QC.
Serge Carrier, MD, FRCS(C), Department of Urology, McGill University, Montreal, QC.

The increase in male life expectancy has raised concerns about the impact of aging on the male reproductive system. Male testicular function declines gradually with advancing age. In general, testicular perfusion is reduced, aging pigment is accumulated, and the tunica albuginea of the testes and basal membrane of the seminiferous tubules are thickened. The function of Sertoli cells and Leydig cells declines. Among the semen parameters, semen volume, sperm motility and sperm morphology are decreased. The hypothalamic-pituitary-gonadal axis is affected at all levels. In some aging men, the reduction of testosterone levels leads to sexual dysfunction and "andropause". Children born to older fathers carry a higher risk of genetic diseases. This review focuses on the effect of aging on the male gonads.
Key words: aging, gonads, fertility, testosterone.

A Review of the Use of Testosterone in Male Osteoporosis

A Review of the Use of Testosterone in Male Osteoporosis

Teaser: 

D'Arcy Little, MD, CCFP, Director of Medical Education, York Community Services, Toronto and Academic Fellow, Department of Family and Community Medicine, University of Toronto, Toronto, ON.

Introduction/Epidemiology
Osteoporosis is a common, serious disease in older adults. Until recently, osteoporosis research and treatment have focussed on postmenopausal women. Recently, however, the epidemiology of this condition in elderly men has become clearer and it is evident that osteoporosis is also prevalent in this population. In fact, men over the age of 50 years have a 19-25% lifetime risk of an osteoporotic fracture, as compared to women who have a 50% lifetime risk. In addition, it is estimated that 30% of hip fractures that occur worldwide occur in men, and lead to significant mortality and loss of independence. Indeed, post-hip fracture, men have a higher mortality rate than do women.1,2,3,4 The role of androgens in bone physiology has suggested that testosterone may be one arm in the treatment regimen. The following article will review the place of testosterone in the management of osteoporosis in males.

Bone Physiology and Pathophysiology
Osteoporosis is a "disease characterized by low bone mass and microarchitectural deterioration of bone tissue leading to enhanced bone fragility and a consequent increase in fracture incidence."5 The origin of idiopathic osteoporosis lies in the aging process and normal bone physiology.